5015 Cornell Road, Agoura Hills, CA 91301
Staff Use Only: _____ Card _____ Rollsheet _____ Measurement Book _____ Computer _____ AOL 5015 Cornell Road, Agoura Hills, CA 91301 (818) 991-8883 www.AgouraHillsDance.com SUMMER CAMP CAMP SUMMER DANCE CAMP 2015 REGISTRATION APPLICATION Required of all students. Must be completed by parent or legal guardian if student is a minor. Today’s Date___________ Class Start Date___________ Staff Use Only: Trial Class / Enrolled Student Name______________________________________ Date of Birth____________________________ Street Address______________________________________ City___________________ Zip____________ Home Telephone__________________ Cell Phone _________________ Alternative # _________________ What school do you attend? How old are you? Email Address ____________________________________________________________________________ *I understand studio information and studio newsletter will be sent to this email address Names of parents or adult family members: _____________________________ Relationship ________________ At same address? Yes□ No□ _____________________________ Relationship ________________ At same address? Yes□ No□ Alternative Address __________________________________ City___________________ Zip___________ Please check which weeks you would like to attend: Check Here th st Week 1 June 15 – June 21 Week 2 June 22 Week 3 July 6 – July 10 Week 4 July 13 – July 17 Week 5 July 20 – July 24 Week 6 July 27 – July 31 Week 7 August 3 – August 7 T-Shirt Size & Color (Circle One) Child Size: Adult Size: nd – June 26 th th th th th th th th st rd __ S __ S th __ M __ L __ M __ L Color: (Circle One) __ Pink __ Blue __ Yellow __ Orange PAYMENT: Date _______________ Amount ____________ Ck/Cash/CC_________ Receipt #___________ Please tell us how you heard about Agoura Hills Dance and Performing Arts Center. _________________ _________________________________________________________________________________________ CONDITIONS OF PARTICIPATION 1. RELEASE AND WAIVER OF LIABILITY AND INDEMNITY: You hereby acknowledge and agree that Student’s use of Agoura Hills Dance & Performing Arts Center LLC (“Studio”) facilities, services, equipment or premises, involves risks of injury to persons and property, including those described below, and Student assumes full responsibility for such risks. In consideration of being allowed to enter Studio and/or to participate in any related Studio events, for any purpose, whether or not at the Studio, including, but not limited to, instruction, observation, use of facilities, services or equipment, or participation in any way, Student agrees to the following: Student hereby releases and holds Studio, its directors, owners, employees, and agents (“Studio Parties”) harmless from all liability to Student and Student’s personal representatives, assigns, heirs and net of kin for any loss and/or damage, and waives any claim or demands therefore, on account of injury to Student’s person or property, including injury leading to the death of Student, whether caused by the active or passive negligence or otherwise of Studio Parties or anyone else, while Student is in, upon, or about Studio premises or participating in any way in any Studio event whether or not at the Studio. Student also hereby agrees to indemnify Studio Parties from any loss, liability, damage or cost Studio Parties may incur due to the presence of Student in, upon, or about Studio premises or observation or participation in any Studio activity whether caused by the negligence or otherwise of Studio Parties or anyone else. You represent (a) that Student is in good physical condition and has no disability, illness, or other condition that could prevent Student from dancing and/or exercising without injury or impairment of health, and (b) that Student has consulted a physician concerning a dance and/or exercise program that will not risk injury to Student or impairment of Student’s health. Such risk of injury includes (but is not limited to): injuries arising from dance and/or exercise activities at the Studio or at Studio related events; injuries and medical disorders arising from exercising such as heart attacks, strokes, heat stress, sprains, broken bones and torn muscles and ligaments, among others; and accidental injuries occurring anywhere in Studio facilities. Student further expressly agrees that the foregoing release, waiver and agreement is intended to e as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full force and effect. Student has read this release and waiver of liability and indemnity clause, and agrees that no oral representations, statements, or inducements apart from this foregoing agreement have been made. 2. INFORMATION – Please provide the following: Medical Insurance Carrier Group # ____________________________ Policy # Alergies, Injuries or Ongoing Medical Problems (please describe fully) 3. PAYMENT: I understand that individual classes must be paid for in advance of the time of instruction, and that all students under the age of 18 are required to pay Monthly Tuition due by the first of each month. I understand that timely payment for all classes is a condition of participation in Studio classes and activities. I agree to familiarize myself with and adhere to the specific Studio policies regarding payment, fees, refunds, etc., which are detailed in the Agoura Hills Dance & Performing Arts, LLC Policy Book which I have received. Check & Initial. I have read this form in its entirety including the above CONDITIONS OF PARTICIPATION and RELEASE AND WAIVER OF LIABILITY AND INDEMNITY and agree to abide by them. If I am a parent or legal guardian executing this agreement on behalf of a Student who is a minor, I understand that the promises and obligations of the Student are my promises and obligations. Signature of Parent or Legal Guardian (or Student if over age 18) Date
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